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The following is a guest blog post by Dawn Crump, VP of Audit Management Solutions at HealthPort.
The RACs are back and they’re offering acute care and critical access hospitals a sweet deal—at least for now.

The Recovery Audit Contractor (RAC) program had been on hold due to the reassigning and re-contracting of regions. In addition, there was a lawsuit pending between Centers for Medicare and Medicaid Services (CMS) and CGI over RAC reimbursement rates, models and approaches. The lawsuit was resolved in August. But CGI quickly appealed causing further delay in full resumption of the RAC program.

So while everyone awaits another court decision and green light from CMS, two important RAC announcements were made by CMS.

A “limited” restart of the RAC program began in August, 2014, including a restricted number of claim reviews and service targets.

Some claims currently pending appeals of inpatient-status claim denials by RACs may be eligible for a partial payment settlement.

Limited Restart Underway

Until the RAC program is 100 percent back in session, some reviews will be conducted. These will be mostly automated reviews, but there will be some records requests and a limited number of complex reviews in certain select areas. During the restart, RACs will not review claims to determine whether the care was delivered in the appropriate setting. CMS said it hopes that the new RAC contracts will be awarded later this year.

From the Aug. 5 edition of the American Hospital Association’s News Now: “CMS will allow current RACs to restart a limited number of claim reviews beginning this month. The agency said most reviews will be done on an automated basis. However, a limited number will be complex reviews on certain claims, including spinal fusions, outpatient therapy services, durable medical equipment, prosthetics, orthotics and supplies, and Medicare-approved cosmetic procedures.

One example of the latter is blepharoplasty, also known as an eyelid lift. The number of claims for this procedure has tripled in recent years, so I expect the RACs will make this procedure a hot target. To be covered under Medicare, vision must be impaired. What’s needed? Physician documentation of the reasons for surgery (e.g., eyelid droop interfering with vision).

Here are three specific steps to take with regard to the limited RAC restart:

Stay abreast of all RAC news and announcements and remain diligent in communicating with your regional peers regarding new RAC region assignments, contacts and educational opportunities.

Conduct an internal probe to ensure you’re following all of Medicare’s National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

Educate coders, billers and physicians around documentation, coding and billing for specific targets as mentioned above.

But the limited restart wasn’t the only important news.

Partial Repayment Deal Announced

In their September 9th, 2014 inpatient hospital reviews announcement, CMS announced an administrative agreement for acute care and critical access hospitals. To reduce the backlog of cases in appeal status and overall administrative costs, these hospitals now have the option to withdraw their pending appeals in “exchange for timely partial payment (68% of the allowable amount)”, according to the CMS administrative agreement.

Of course there are parameters to understand and details to sort out regarding the settlement opportunity. Here is what we know so far:

Only acute care and critical access hospital claims are eligible.

Claims must already be in the appeals process for inpatient-status claims with an admission date prior to October 1, 2013.

Services might have been found reasonable and necessary by the Medicare contractor, but treatment as an inpatient was not.

Hospitals may choose to settle some claims and continue to appeal others.

Hospitals should send their request for settlement to CMS by October 31, 2014.

Eligible hospitals must determine if requesting a settlement offer makes sense for cases in appeal that meet the specified parameters. For some cases, it will make sense to take the 68 percent settlement and cut your losses. For other denials, waiting out the appeal process may be a better choice.

Each denial will be different and each case unique. Time, money and resources must be balanced against the potential revenue retained or returned potential. Audit management directors, in conjunction with their revenue cycle and finance teams, must analyze RAC data for each eligible case. It’s a complicated equation. And with a deadline of October 31, 2014, there is no time to lose.

About Dawn Crump

Dawn Crump, MA, SSBB, CHC, has been in the healthcare compliance industry for more than 18 years and joined HealthPort in 2013 as Vice President of Audit Management Solutions. Prior to joining HealthPort, Ms. Crump was the Network Director of Compliance for SSM. She is a former board director of the Greater St. Louis Healthcare Finance Management Association chapter and currently serves as the networking chair.

The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Now that we’re well on the road to being meaningful users of an EHR, I thought it would be interesting to take a step back and look at the ROI of an EHR investment. Hopefully this will be a valuable resource for those still considering an EHR investment and those who’ve already adopted an EHR in their practice. Some of the items listed below are benefits you receive automatically just by using an EHR. Other benefits require some thought and effort on your part. Hopefully this list will remind you of EHR benefits you might have forgotten and ones you can still work to achieve.

Repurpose Space – One of the big advantages of EHR software is that you can store your entire chart room on a relatively small server. Plus, if you’re using a hosted EHR solution, you don’t even need space in your office for a server. Once your paper charts get scanned into your EHR, you can often repurpose your chart room into a revenue generating exam room. I’ve seen some cases where an extra exam room made it possible to bring on another doctor or mid-level provider. In other cases, the extra exam room was able to make existing doctors more efficient. Either way, I don’t know very many practices who say, “We have too much space.”

Eliminate or Repurpose Staff – Nobody likes the idea of eliminating staff as part of an EHR implementation. However, there are two ways I’ve seen organizations reduce staff after implementing an EHR. First, some organizations reduce their staff through natural employee attrition. When a member of your staff chooses to leave your organization, some organizations decide not to replace that staff member since many of their duties are no longer needed in an EHR world. Second, some organizations take their existing staff and repurpose them to perform other tasks. For example, I’ve seen HIM (medical records) staff who are also medical assistants switch to more of a clinical role in the organization after implementing an EHR.

Avoid Penalties – One of the best reasons to make an early investment in an EHR is to avoid the government penalties. I’ve written about the meaningful use and PQRS penalties before, but this is likely just the start of the penalties the government and private payers will implement on those who don’t use an EHR. The long term ROI of these penalties is very large for most practices.

Quality Measures and Value Based Reimbursement – Meaningful Use together with the Value Based Reimbursement Modifier (VM) are the start of a shift towards reporting and getting paid based on clinical quality measures and outcomes. EHR software is at the center of this shift and will be essential to easily document and report these measures and outcomes. While we can put a hard number on the EHR incentive payments that are tied to these measures and the VM, you can be certain that this number will only continue to grow as the government and payers require more data.

Improved Charge Capture – Eight years ago, improved charge capture was the main ROI mechanism that EMR vendors used to sell software. The idea being that the EMR could help you more fully document the patient visit and thus allow you to bill at a higher level than you were doing previously. As in most things involving money, some doctors took this too far and started using the EMR to over code visits. These EHR over code abusers aside, the majority of doctors I know are chronic under coders. Many of these doctors under code because they don’t want to spend time documenting the normal findings that would let them code at a higher level. A well implemented EHR can help doctors fully document even the normal findings in a visit and therefore allow them to bill at a higher level.

Cancel Transcription – Depending on how you use (or don’t use) transcription, this may or may not be a part of your EHR ROI calculation. While transcription can still be used with an EHR, the majority of EHR users stop transcribing as part of the EHR implementation process. Once you make the switch to documenting directly in the EHR or using voice recognition, it’s easy to forget how much money you were spending on transcription.

Improved Workflows – A well implemented EHR software can improve your clinic’s workflows. The lab result workflow is a great example of how an EHR can improve the workflow in your office. The amount of time saved ordering labs and retrieving lab results in an EHR world is significant. Sure, lab interfaces aren’t perfect, but they’re a lot better than the paper model. You can see similar workflow benefits from X-rays and even a well implemented patient portal. Of course, your workflow can be negatively impacted if you’re not careful and thoughtful in how you implement your EHR. However, EHR technology can do a lot to improve a clinic’s workflow when you replace time intensive paper processes.

Streamlined Internal Communication – Related to improved workflows is improved communication. When it comes to internal office communication, most EHR software comes with a secure internal messaging service or task system. This replaces all those sticky notes, stacks of charts, or notes in boxes that would occur previously. Now messages aren’t lost and can be more easily tracked in the internal EHR messaging. Plus, you can also often report on how fast tasks are being completed.

Streamlined External Communication – We’re still early in EHR’s ability to facilitate secure communication with external providers. While some EHR software offers a provider portal for this communication, I’m more interested in the progress of Direct Project which allows the secure transfer of patient records between doctors. As these technologies mature, the time saved at the fax machine and sorting data records will be tremendous.

Eliminate Paper – Once you implement an EHR, you quickly forget how much money you were spending on paper and paper charts. Don’t forget to think about this cost savings when looking at the value of EHR. While some paper just disappears post EHR implementation, you’ll likely find that there’s still plenty of paper lingering around your office. You’ll never eliminate all of the paper from your practice, but you should ask yourself if you really need the paper you’re using or if it’s just part of an old practice that’s no longer needed. Furthermore, many EHR enabled offices print off insane amounts of paper from their EHR for no reason. This extra cost can be avoided with a little planning and awareness.

Chart Search Time – This is another one of the EHR benefits that quickly gets taken for granted. In the EHR world, it is extremely simple to find the right chart. I don’t need to outline the challenges that existed in the paper world with finding the paper charts. Medical records staff were amazing at organizing and finding paper charts, but this all required a lot of time organizing and locating the right chart. This is all but eliminated in the EMR world.

Along with the financial and efficiency benefits mentioned above, there are lots of other benefits to using an EHR like: legible notes, drug to drug interaction checking, and ePrescribing to name a few. However, even more important than all of the benefits mentioned above is how important an EHR will be to future reimbursement and care. As was mentioned, Medicare’s started penalizing non-EHR users and we’ll likely see other payers in some form or fashion follow their lead. Along with current and future EHR related penalties, there’s a real risk that you won’t be able to practice the highest quality medicine without an EHR and the future technologies it facilitates. The medical standard of care will likely require an EHR.

The following is a guest post by Barry Haitoff, CEO of Medical Management Corporation of America.
Healthcare has always been a deeply regulated industry, so in many ways healthcare organizations are already used to dealing with government scrutiny. However, we’ve recently seen a number of new audit programs hit the healthcare world that didn’t exist even a few years ago. Here’s a look at a few of them you should be prepared for.

Meaningful Use Audits
This is one of the newest audit programs to hit healthcare. Depending on your attestation history, it could have a tremendous impact on your organization’s financial health. These EHR incentive audits have been happening across every size organization and are conducted by the CMS hired auditing firm, Figliozzi and Company of Garden City, N.Y. If you get a letter or email from Figliozzi you’ll know what it is right away. An EHR incentive audit is a big deal since the meaningful use program is all or nothing. If they find even one thing wrong with your meaningful use attestation, you could lose ALL of your EHR incentive money.

CMS recently released an informative guidance document outlining the supporting documentation needed for an EHR incentive audit. Pages 4 and 5 of the document go through the self-attestation objectives and others detailing the audit validation and suggested documentation needed for each. If you’ve attested to meaningful use, then you’ll want to take some time to go through the document to make sure you can provide the necessary documentation if needed. In many cases this simply includes dated screenshots to prove measure completion. While many EHR vendors can be helpful in the meaningful use audit process, you should not totally rely on them.

In a recent blog post, Jim Tate makes a compelling case for why you might want to consider doing a mock EHR incentive audit and how to make sure that the audit is effective. Although smaller organizations won’t likely be able to afford an outside audit, having it done by someone in your organization that wasn’t involved in the attestation is beneficial. The CMS guidance document could be used as a guide. A mock audit could help discover any potential issues and help you put mitigation strategies in place before you have a real audit and your hands are tied.

Recovery Audit Contractor (RAC) Audits
RAC audits are currently on hold as CMS works to improve the program and deal with the enormous audit backlog. We still haven’t heard from CMS about when the RAC audits will resume, but we should hear something later this summer. While no RAC audits are occurring right now, that doesn’t mean that once the RAC audits resume, the claims you’re filing today can’t and won’t be audited.

The best thing you can do to be prepared for RAC audits is to make sure that your documentation and billing ducks are in a row. A great place to start is to look at your most common denials and look at how you can improve your clinical documentation, coding and billing for each of these denials. Also, make sure that your process for responding to audits is standardized and effective. The RAC audit is just one example of an audit performed by payers. Don’t be surprised if you’re subjected to audits from other agencies or commercial payers.

RAC audits recovered billions of dollars in overpayments in recent years. You can be sure that they will continue and that other similar initiatives are coming our way. There’s just too much incentive for the government not to do it.

HIPAA Audits
The US Department of Health and Human Services’ Office for Civil Rights (HHS OCR) first started doing HIPAA audits as part of a 2011 pilot program. It’s fair to say that HHS OCR’s audit program was one of discovery as much as it was of compliance. However, the HITECH Act and Omnibus Rule have started to up the ante when it comes to enforcement of HIPAA. HHS OCR announced that they’d be surveying 800 covered entities and 400 business associations to select the next round of audit subjects. An OCR Spokesperson said, “We hope to audit 350 covered entities and 50 BAs in this first go around.”

Unlike previous audits that were done by KPMG, these HIPAA audits will be done by OCR staff. One area that these audits will likely focus on is the HIPAA Security Risk Assessment. The importance of doing this cannot be understated and is illustrated by the fact that it’s a requirement for meaningful use. I will be surprised if these audits don’t also focus on the new HIPAA Omnibus Rule requirements. I’m sure many of the HIPAA audits will catch organizations that never updated their HIPAA policies to comply with HIPAA Omnibus.

Summary
No one enjoys an audit of any sort. However, being well prepared for an audit will provide some level of comfort to yourself and your organization. Now is your opportunity to make sure you’re well prepared for these audits that could be coming your way. These audit programs likely aren’t going anywhere, so take the time to make sure you’re prepared.

The following is a guest blog post by Dawn Crump, VP of Audit Management Solutions at HealthPort.
2014 brings the first significant break in RAC activity for healthcare providers. Hospitals have been taking advantage of the RAC break to assess current programs, review historical data and centralize their audit management processes.

Steps taken now to improve RAC processing will drive significant returns when the RACs reconvene. This article highlights recent RAC announcements and three process improvement steps to take now…while you have the time.

What’s New with RACs?

There are no new record requests sent by RACs to hospitals (pre-payment requests stopped on February 28) and no additional documentation requests (ADRs) for now (post-payment requests stopped on February 21). While programs were initially expected to revamp this month, there has been no announcement from CMS (I don’t anticipate one until later this summer).

Secondly, CMS announced that administrative law judge (ALJ) delays may extend upwards of twenty-six months, leaving providers holding the bag for cases already in appeal. And finally, the passage of H.R. 4302 (the infamous SGR patch) in April 2014 delayed implementation of ICD-10 and extended the timeframe prohibiting review of two-midnight rule by RACs.

Three Areas to Focus

Perhaps 2014 is the year for delays. If so, providers are the benefactor. Here are three important areas to assess during the delay.

Top 10 Lists

Healthcare is riddled with lists. Medicare’s recent list of highest-priced surgeries and DRGs is a good place to identify future RAC targets. . Take a good look at this report and any others relevant to your organization. They point the way to future RAC reviews.

Short stay admissions

Medical necessity rules surrounding short stays are changing due to the Two Midnight Rule. Include short stays in your internal documentation audits and be aware that other third party payers are following the RACs’ lead.

National reports

Analyze most recent RACTrac and PEPPER reports and see how you compare. These reports are great places to find clinical documentation and coding improvement targets in ICD-9 while you wait for the RAC program to restart.

RAC Data: Take a Closer Look

Your historical RAC data is another goldmine of improvement opportunities and steps to mitigate future risk. Take a hard look at your data and ask yourself these questions:

How many cases and dollars are awaiting appeal? Where are these cases in the appeal process?

Are any cases eligible for rebilling? If so, should they be rebilled?

What are our most common denials and can we improve documentation, coding and billing for these cases?

Is a deeper level of data analysis needed? Can our audit tracking software drill down further for better business intelligence?

Centralize Your Audit Management Efforts

Finally, there’s no way around it. Audit management is expensive.

When employees repeat the same audit processing steps across multiple locations and departments, your costs skyrocket. Now is a great time to centralize your audit management process to:

Reduce administrative costs associated with RAC audit processing.

Eliminate duplicate audits and redundancies.

Establish consistent policies, procedures and workflows.

Bolster internal audit knowledge and expertise.

Most hospitals have already centralized their business offices (CBOs). Centralizing the audit management function, including RACs, is a natural next step. Take a close look at audit processing across your entire organization looking for these costly inefficiencies.

Each HIM department may be processing and tracking RAC requests differently.

Each case management department may be reviewing RAC denials differently.

Staff spending up to 25% of their time on audits, but no one making RAC a priority.

By creating a centralized team, you establish lean processes and reduce overall costs associated with audit management. RAC is the best place to start since there are already established guidelines and rules. Once established, expand your centralized department to other audits (e.g. OIG, MACS pre and post payment, Medicaid, ZPICS, etc.)

The Summer Ahead

Beyond the steps mentioned above, I encourage you to remain vigilant with regard to other forms of audits, including commercial plans, MACs (Medicare administrative contractors) and Medicaid audits . We all have some breathing room with regard to RAC, but preparation is key.

About Dawn Crump

Dawn Crump, MA, SSBB, CHC, has been in the healthcare compliance industry for more than 18 years and joined HealthPort in 2013 as Vice President of Audit Management Solutions. Prior to joining HealthPort, Ms. Crump was the Network Director of Compliance for SSM. She has healthcare experience in education, organization development, quality improvement and corporate compliance.

Trained as a six sigma black belt, Ms. Crump used this holistic, fact-based approach to establish audit tracking (RAC) programs. Her expertise includes coding and billing compliance as well as HIPAA compliance and government audit programs for acute care facilities. She is a former board director of the Greater St. Louis Healthcare Finance Management Association chapter and currently serves as the networking chair. Ms. Crump is also a member of the Health Care Compliance Association (HCCA).

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

While at AHIMA 2013, one of the big topics people were discussing was all of the audits that the HIM staff are having to deal with on an ongoing basis. Everyone that I talked to said that there is no end in sight when it comes to the various audits. In fact, most were predicting even more audits to come.

I sat down with Dawn Crump, VP of Audit Management Solutions from HealthPort, to find out some suggestions for organizations trying to deal with this wave of audits in healthcare. Check out the video below to hear those suggestions (plus, she throws in a fourth and fifth bonus suggestion):

How is your organization dealing with all of these audits? Have you formalized and streamlined the process in your organization? Do you have an easy way to track all of your audits? Do you know the financial impact of these audits on your organization?

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Last night during one of my favorite TV shows, Charlie Rose, he interviewed a guy about the economy. One of the discussion points that came out of this interview and that I’ve heard a lot in all the discussions about the economy is having some stability to the economy. Many argue that one of the biggest things holding our economy back is all the unknowns. When there are unknowns companies get paralyzed and hold back doing things they’d do if the economy felt stable.

I wonder if we’re experiencing the same thing in healthcare IT? Could we use some stability in healthcare IT?

Think about all the various unknowns that exist in healthcare IT. Let’s start with ICD-10. The pending ICD-10 implementation date is looming, but that date has been pushed back so many times it’s still unknown if it’s really going to happen this time. That’s the opposite of stability.

I’m sure that many also wonder if the same will be the case with EHR penalties. Will the EHR penalties go into effect? What exceptions will be made for the EHR penalties? I could easily see the EHR penalties being delayed, but then again what if they’re not?

Is it hard for anyone else to keep up with what’s happening with meaningful use? I do this every day and so I have a pretty good idea, but even I’m getting confused as it gets more complex. Imagine being a doctor who rarely looks at meaningful use. So, we’re in meaningful use stage 1, but meaningful use stage 2 is coming, unless you didn’t start meaningful use stage 1 and then meaningful use stage 2 won’t come until later. Oh, and they’re making changes to meaningful use stage 2. That’s right and they’re also coming out with meaningful use stage 3. However, don’t worry too much about meaningful use stage 3 because a lot of people are calling for it to be slowed down. So, does that mean that meaningful use will be delayed? Now how does the meaningful use stages match with the EHR certifications? Which version of my EHR software does which stage of meaningful use?

I think you get the picture.

Of course, I haven’t even mentioned things like ACO’s, HIE’s, 5010, HIPAA, RAC Audits, Medicare/Medicaid cuts, or healthcare reform (ACA) to name a few others.

It’s a messy healthcare IT environment right now. We could definitely use some stability in healthcare.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

From my blogging viewpoint I’m sensing a growing discontent among doctors that is starting to really heat up. I can’t quite predict when this discontent will reach a boiling point that will start to boil over, but the fireworks are coming. As I’ve watched the past couple years, doctors were first overwhelmed with all the government regulations. They were confused by everything was coming out and really just didn’t know where healthcare IT and EHR was headed. That overwhelmed confusion is slowly turning into a reality that many doctors are realizing is changing how they practice medicine. If you’re not seeing this, then you might want to get out and spend some more time with your casual every day doctors.

One doctor emailed me today suggesting that doctors were being literally “eaten alive” as they are working harder to provide patient centered care. It would be a disservice to doctors if we don’t take the time to acknowledge and understand the enormous pressures that many doctors are feeling right now.

Here’s a quick look at what I believe is the perspective of many doctors I connect with on a daily basis.

Regulations
Everywhere doctors look they’re getting hammered by new regulations. I recently heard Shahid Shah say, “We’re experts in the industry that spend all day thinking about the market and regulations and even we have a challenge understanding what’s going on. Now think about the doctors and adminstrators which have challenging day jobs and only a small amount of time to understand the regulations. They don’t really understand the details of what’s being regulated.”

This is a reality for many doctors and practices. Is it any wonder that many are happy to sell off their practices to major hospitals? I’m sure that many do so just because they’re tired of trying to understand all the changing regulations they’re required to know.

If we look at just the healthcare IT and EHR related regulations you have: meaningful use, ACOs, ICD-10, 5010, and Obamacare/Healthcare Reform. Any one of those is a challenge to understand and implement. Yet doctors and hospitals are dealing with all five of them simultaneously. Not to mention doctors being asked to participate in HIEs, being graded and rated online, engaging with empowered patients through social media, and embracing a new technology savvy culture while reimbursement lags behind.

Is it any wonder that doctors feel overwhelmed, overworked, and unsure whether they want to continue being doctors. Is this going to lead to a real shortage of medical professionals?

EHR Discontent
Since this is an EHR blog, we should spend some time on the growing discontent with EHR software. I hate to dwell on this, because EHR is going to be the future of clinical documentation. It’s hear to stay and no amount of belly aching and moaning is going to stop EHR software from becoming the de facto standard for clinical documentation. However, just because this is the case doesn’t mean we should ignore the realities that so many doctors are facing when it comes to EHR software today.

Many doctors see EHR as a major time suck. Their EHR software requires them to work longer hours and/or see fewer patients. Overtime this usually improves, but we have to acknowledge the initial productivity hit that pretty much every EHR implementation sees. Some clinics never get back to their previous productivity. We’ve discussed the reasons for this over and over again on this blog. We’ll save the list of reasons and ways to avoid those issues for another blog post. However, until all 300+ EHR vendors solve the EHR productivity issue, we’re going to hear more and more stories of how much of a time suck an EHR is to many doctors.

Not all doctors see it this way. Many doctors can’t imagine their practice without an EHR. As we’ve been covering in our EHR Benefits Series, there are a lot of benefits to having an EHR. Many of the benefits we’ve already covered in that series are ways that a clinic can save time thanks to an EHR. However, it can take time for a new EHR user to get up to speed where they can speak the EMR language well. It’s not easy learning a new language, and so this adds to the growing discontent that many doctors feel towards EHR.

Template EHR and Copy Paste
Many EHR vendors have implemented a complex set of templates that doctors can use to be more efficient. It’s a thing of beauty to see a full template pulled into a patient’s chart with a single click. A full patient physical documented with a single click sounds like it should save the doctors a lot of time and make them more efficient. In fact, many have argued that template based EHR documentation is a great way for doctors to achieve higher reimbursement levels since they are better able to document the actual care they’re providing. In the paper world they would have passed on the higher reimbursement because they didn’t have the time or desire to document all of the items they examined and so they just accept a lower reimbursement level. EMR templates made it possible for doctors to finally be reimbursed for all of the care they provided a patient since the templates made it easy to document.

Sounds great doesn’t it? Well, it did until the government realized that EHR software often drove up their costs. This shouldn’t have been a surprise to anyone in the EHR world. I’ve been writing about the ability to increase your reimbursement rates from EHR for over 7 years. However, instead of the government choosing to acknowledge something that was apparent to many in the industry, they decided to blame the increased costs on, you guessed it, dishonest doctors.

Think about the message that we’re sending doctors. First the government tells doctors to start using EHR. Then, the government calls those doctors dishonest for using the tools that the government told them to use. A doctor recently described their perspective is like being stuck in a pit with sly hyenas all around ready to take their bite out of them.

Add in all the recent discussions about copy and paste in EMR’s, and it shouldn’t be any wonder that doctors are gun shy. When they implement technologies to try and make things more efficient they get their hands slapped or even worse.

Reduced Reimbursement and Penalties
In the midst of all the things mentioned above, doctors are also getting hit with reduced reimbursement rates. This is particularly true for those in the general medicine area. They’re being asked to do more to improve patient care, reduce hospital re-admissions, treat the whole patient, etc and they’re getting less reimbursement.

Plus, now the EHR penalties are hanging over their head if they choose to not show meaningful use of a certified EHR. I still have my doubts that the EHR penalties will be enforced. I expect there will be a whole series of exceptions offered up which make it so pretty much all of the doctors avoid the penalties. However, that’s still unknown and many doctors see those EHR penalties as just another slap into the face.

Data Data Data
Most doctors see the push for EHR as a way for someone to get at the data in healthcare. In many ways, they’re right. EHR’s were first created as big billing machines to get at the financial data. Now with meaningful use, EHR’s are repositories of other healthcare data. The data is being used to optimize reimbursement (rarely a good thing for doctors). The data is wanted for population health analysis. The data is wanted for public health needs. The data is wanted to be able to facilitate ACOs. Everyone wants a piece of the healthcare data it seems.

The problem from a physician perspective is that everyone wants that data, but it’s not often clear how that data is going to facilitate that doctor being a better doctor. In many cases it won’t and there’s the rub. Almost every doctor I know wants to improve healthcare. So, they don’t have any problems supporting initiatives that improve healthcare, but I think that most of them also sit back and wonder at what cost.

Audits
I don’t know anyone that likes audits. Yet, most doctors are surrounded by a wide variety of audits. RAC Audits are on the way. HIPAA audits are possible and HIPAA is always lingering in the back of most doctors minds. Especially when you start talking about technology and HIPAA. There are so many unknowns that there’s no place of comfort for those doctors who want to be compliant. Most make a best effort and then push it out of their minds as they try to provide great patient care. Next up our meaningful use audits. You can be sure they’re coming.

Solutions
I wish I could say that I have a bunch of really good solutions available. What does seem clear to me is that most of the challenges that doctors face revolve around the current reimbursement models that we have today. I’m not sure we can fundamentally change those. One interesting option that’s emerging is concierge medicine.

Every doctor I know loves the idea of concierge medicine. When you tell them they don’t have to worry about reimbursement, insurance companies, etc, you see this huge weight lifted off of their shoulders as they wonder what life would be like for them if all they did was provide the best patient care to those who came to their office. The problem with concierge medicine was highlighted in a tweet I saw recently that said, “Concierge Medicine – Does it really work?”

The answer to that question is: it’s still too early to know for sure. Although, my prediction is that concierge medicine will work in certain situations and communities, but won’t be able to provide the widespread change of reimbursement that we need for healthcare to alleviate doctors concerns.

When it comes to EHR, concierge medicine is quite interesting. None of the mainstream EHR vendors really work for concierge medicine since they’re all focused around reimbursement and concierge throws that out the window. Plus, think about how few of the meaningful use requirements a concierge medicine clinic cares about. In fact, implementing many of the meaningful use and EHR certification requirements gets in the way of the concierge doctor’s workflow. I expect many doctors would love a concierge focused EHR software.

The other solution is likely going to be EHR vendors yielding to the idea that they’re the database of healthcare. Once they make this decision, EHR vendors can really open up the proverbial EHR kimono and let outside developers really make their EHR useful for doctors across all specialties, all regions, all sizes, and every unique workflow. One company can’t satisfy every doctor the way a community of empowered developers can.

No One Feels Bad for Doctors
I’ve written about this idea before, but almost no one feels bad for what most people think of as “well paid doctors.” Far too many doctors are still driving around Mercedes and BMW’s for most people to feel too bad for them. Compared to many people who don’t have a job at all, I don’t feel bad for them either.

While we don’t have to feel sorry for them, that doesn’t mean we shouldn’t acknowledge the pressures that doctors are facing. Plus, I see this only getting worse before it gets better. As an entrepreneur, I see this as a tremendous opportunity. Plus, I see a number of companies that are working to capture this opportunity. However, far too many companies are blind to this physician discontent. I’m not sure if it’s purposefully blind, ignorantly blind, or arrogantly blind, but many are ignoring it. As I predicted in the beginning of this post, I see this reaching a boiling point soon which leads to some fireworks.

Let me highlight what I’m talking about using the words of a doctor’s message I literally received in my email as I was writing this post:

EMR’s are making it more and more difficult to practice medicine. They used to be fun and helped my daily work. Now, they are getting so complex that is takes much more time to do them. MU is becoming a nightmare for physicians.

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Lori Brocato is Director of Audit at HealthPort. With more than 15 years in health care technology, Lori serves as HealthPort’s resident government and third party audit expert, sharing educational information and best practices with health care facilities via Webinars, media interviews and industry articles. Additionally, she is the AudaPro product manager for HealthPort and authors her own blog, Audit Insights, on the HealthPort website. Lori is also a monthly contributor for RACMonitor, an online knowledge source for healthcare providers. She is RAC certified by the Medicare RAC summit and a member of HIMSS and HFMA.

Taking Paper Out of the Audit Process
The amount of provider and governmental resources now dedicated to processing and managing recovery audits is staggering. According to the American Hospital Association RACTrac Survey in May 2012, 76% of participating hospitals reported that RAC activity had increased their administrative burden including additional costs, training, software and full time equivalents needed to manage the workload. Similar findings were reported in the August 2012 RACTrac report.

Costs to cover the growing administrative load range from $10,000 to over $100,000 per quarter. Nine percent of hospitals spend over $400,000 annually to manage audit. And when multiple auditors come after the same encounter, expenses rise. The majority of these costs come from producing copies of medical records, sending them to review contractors, and managing appeals.

Making RACs a Paper-Free Zone
When RACs and other auditors need medical records to conduct their reviews, they request them by submitting a formal letter to the provider. These request letters land in the Audit or HIM department where internal staffs or outsourced Release of Information (ROI) companies find the requested records, produce photocopies and submit paper to the auditor.

Three Provider Options
Along with esMD, many ROI companies and other Health Information Handlers (HIH’s) have developed private exchanges. Providers have three choices to reduce the paper burden of RAC and other audits. They can build their own esMD gateway using the CMS CONNECT architecture, connect to esMD through an HIH, or use the HIH’s private exchange. All three options result in the following four benefits:

Elimination of paper and postage

Increased automation request delivery

Improved tracking

Faster delivery

However, since HIHs have already established connections either through esMD or a direct, private audit exchange, providers save time and IT expense by using an HIH.

Direct Connections: What Providers Need to Know
Because the number of auditing bodies continues to expand and reach of recovery contractor activity continues to grow, the use of direct audit connections (or exchanges) may outpace submissions through esMD. Direct exchange by an HIH uses a one-to-many connection with auditors and provides four benefits:

Request letters from RACs and other auditors can be received electronically.

One access point is established by the provider and from there, the HIH is responsible for establishing all the various auditor connections; saving time and IT resources.

Providers have a secure, private portal with end-to-end tracking capability for all audit record requests.

Providers can obtain a FedEx comparable tracking number instead of just a date and time stamp confirmation.

Paper’s Coming Out of the Process….It’s Only a Matter of Time
Audits will continue. Demands for medical records will expand. Administrative burdens will increase. These are the realities of today’s pay-and-chase model. However, new technologies to cope are emerging.

These technologies, in concert with centralized audit management and EHR advances, are poised to reduce administrative burdens and move audit processing from “paper-intensive” to “paper-free”. The future of audit management will be paper-free: one way or another!

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

EMR templates are coming under increasing fire of late, with regulators arguing that they’re not doing a good job of justifying the reimbursement that doctors are requesting. Now, in a move that can only be described as racheting up the pressure, CMS has revised its instructions to Recovery Audit Contractors (and their brethren) to demand that they look more closely at template documentation.

According to a report in EHR Intelligence, CMS has issued new orders asking RACs and other recovery contractors to review templates, extract usable data, and use that to determine whether reimbursement requests are legit. Specifically, it’s asking contractors to focus in on limited space progress note templates and open-ended progress note templates.

CMS isn’t asking providers to stop using templates, but it does seem fairly disapproving, particularly of limited space templates, which it regards as largely inadequate for payment purposes

“Review contractors shall remember that progress notes created with Limited Space Templates in the absence of other acceptable medical record entries do NOT constitute sufficient documentation of a face-to-face visit and medical examination,” the agency says in its contractor instructions.

The agency notes that templates using checkboxes and predefined answers to enter information generally don’t work. “Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met,” the instructions note.

Well, there you have it. You’ve got an agency that’s coming down hard on the use of inadequate templates, but “does not endorse or approve any particular templates.” Seems like a recipe for disaster.

If CMS refuses to propose a specific template design, I say it’s incumbent on the industry to do so. With so much at stake, it’s time to lay out a design that vendors and providers can live with and hand it to CMS. Maybe that will spur the agency to take a stand.

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